1) Do you have an app that you liked for backing up your content on here? I'd like to download it all, with comments, just in case it all eventually disappears.
1a) I know that there's an export feature, but it only does one month at a time and doesn't include comments.
1b) I guess I could copy & paste each entry into a giant word document.
2) Other than Facebook, where do you hang out?
Really ( long update about work, and what I'm learning. )
We sign all sorts of statements saying we won't reveal anything that's on the exam, so I won't. I will say that it was hard, and I genuinely feared that I had failed it. I received my Approval To Test 3 weeks to the day after graduation. I had been worried about this--it wasn't clear exactly how quickly it would arrive, and then I'd heard rumors that "there were no test dates in NYS until after July," which was completely false. When I received the ATT, I had the choice of taking the exam on the 18th (5 days later) or waiting until at least the 28th of this month to take it. The only available test center on the 18th was 1.5 hours away, but I decided to go for it anyway. I was feeling so tense and restless that I thought it would just be better to take it and get it over with. So, I registered for the 18th and ramped up my studying for the next 5 days! I also made myself start (trying) to go to bed earlier and get up earlier, since I needed to leave the house at 5:30 in the morning the day of the exam.
I felt reasonably confident the morning of the test, though there were things I wished I'd reviewed more. The testing center is a medium-high security place--each NCLEX applicant is photographed, fingerprinted, and has an infrared image made of the veins in their palms (more difficult to fake than fingerprints). I had to empty my pockets and turn them out. Nothing could be brought in or out of the test room except my driver's license and the key to my locker. I'd left my cell phone in the glove box, but otherwise they would have sealed it into a bag so that I couldn't look at it on breaks.
The NCLEX has a 6 hour time limit, but the number of questions varies between 75 and 265. It's an adaptive test, so the theory is that it tries to present questions that you have a 50% chance of getting right, based on your performance on previous questions. The questions are selected from certain domains (such as "Health Promotion"). They don't publish what percentage of questions you have to answer correctly in order to pass. The exam simply turns off when you have answered enough questions for it to decide whether you've passed or failed. I only had 75 questions, but it felt like 1/4 of them were "select-all-that-apply" questions, which are really like 5 or 6 questions in one.
After the exam, I left and drove home, listening to a re-broadcast of Morning Edition that I'd already heard on the way there. I felt pretty okay for the rest of the afternoon, but by evening I started remembering questions and becoming convinced I'd answered them wrong. The next day was the same. I'd try to rationalize--"86% of applicants pass the NCLEX, and you always did well academically," but it didn't help. If anything, it made it worse--what if I'd graduated at the top of my class, only to fail the exam? I tried to distract myself by working on a couple of projects, and Eric was very kind to me, but really the only thing to do was grit it out and wait until Thursday morning when I could pay a fee to check my results....
I've finished! I graduated with High Honors on Thursday the 23rd! (This entry is a couple of weeks behind...)
So, week 17 included more of my 'bridging' clinical days. I had 2 more 12-hour shifts, one with a different preceptor, and an 8-hour shift. I worked on being able to care for 3-4 patients fairly independently (as independent as I could be considering I can't remove medications from the computerized cabinet, the preceptor has to check all medications and supervise all IV procedures anyway, and I can't transcribe or verify new orders from the physician's order-entry system!).
Week 18 started with my very last clinical day on Monday, followed by my final evaluation with my instructor. With this completed, I turned in my Graduation Checklist to the main office, along with surrendering my ID badge. (Other items on the checklist included Financial Aid exit counseling, presenting the mandated-reporter certificate required by NYS for all nurses and others who could encounter children in their practice, updating my address, etc...).
Tuesday was the Pinning Ceremony/Convocation. This was held in a hotel ballroom. Each graduate received a pin from the College, presented by a faculty member of our choice or by a family member who is a nurse. Nursing pins have a long tradition, although it seems they are mostly worn at formal events now. (The white starched cap was unique to each nursing school as well, and when nurses wore white uniforms I think wearing a pin with the uniform was more common. Now, though, no one wears white caps and everyone wears scrubs.)
Thursday was the Graduation ceremony. This was held in the chapel of the big university here in town. It's an old building, with no air conditioning! Fortunately, it wasn't too hot that day. We all processed in caps & gowns, received our diplomas onstage, etc... Most of the faculty attended in caps and robes as well (nearly all of the faculty have MS degrees or higher).
So, what's next? I need to study for the NCLEX exam, and I need to refrain from tearing my hair out while I wait to schedule a test date. NYS won't give approval to take the test until they've received proof of graduation from the school, which is apparently sent by carrier pigeon. (We've been told it takes 3-4 weeks after graduation to get approval.) I'm antsy because 1) my job depends on me taking it before I start!, 2) I've heard rumors that it's very difficult to actually get a test date this year (also see #1), and 3) it's hard to study or plan when I don't even know when the exam will be!
In the meantime, we've put in our garden, but iffy weather this week means we might need to replace a few seedlings. We had frost warnings Sunday night but it's supposed to be 90° on Friday...that's hard on tiny seedlings! We're expecting a visit from my aunt and uncle in a few weeks (crossing my fingers that this doesn't somehow interfere with the test!). I'm hoping we might get a chance to go to VT before I start work, but we can't plan anything until I have that date!
On Tuesday we took our very last computerized exam, which is meant to predict your probability of passing the NCLEX on the first try. Based on your performance on the exam, it designs a "study" plan for you and gives you a coach to work with. (This has all been paid for via our tuition, but I'm still skeptical since I haven't loved this computerized-testing company throughout school. However, we're not required to use their review materials; just to take the predictor exam.) I did very well on the predictor, but of course I still plan to do a lot of studying after graduation.
Wednesday-Friday I didn't have any official school obligations, but I did have my employee physical/TB test/drug screening, and picked up my cap and gown, and other exciting tasks.
Saturday and Sunday were my first two days of our final "bridging" clinical work. During this time we work with a preceptor nurse, and an instructor checks in with us once a day. We have to submit brief journal entries, but not the full-length self-reflections we've had to do for other classes. I worked 12-hour shifts both days (the shifts are assigned to us). I was definitely tired last night! I haven't been on my feet for 12 hours at a stretch for a long time--it takes some getting used to! I'm off today and then back tomorrow, Thursday, Friday, and next Monday (the day before convocation). I felt like both days went pretty well. During this time we're supposed to be demonstrating increasing independence and judgment, and also working up to caring for 3-4 patients at a time.
Today, the car is in the shop getting a lot of expensive work done...good thing I should be earning a paycheck in a couple of months!
We had another computerized exam, which actually went pretty decently. These are administered by an independent company, so the topics on the exam aren't always things we've specifically learned about in class. There were a few questions like that on this exam, but not too many.
And...that was the week! I did spend Thursday morning shadowing an RN on a floor where I had a job interview. More about that if it pans out...
The lectures were pretty intense, though; we learned about head injuries and spinal cord injuries. We have an exam on Tuesday that I plan to study a lot for! Then on Wednesday we have one of those computerized exams. It's only worth 5% of our grade, but I still don't like them very much. I was sad this week to run into a friend of mine whose grades have always been a bit borderline. She's made it through every semester so far, but I had known that she was not doing well this semester. After our 4th exam, it was determined that, mathematically, it would not be possible for her to pass the class. I ran into her in the faculty offices where she was going into a meeting about withdrawing and trying again in the fall. (Unfortunately, the deadline to 'withdraw' has passed, so she gets an F for the semester and no refund of any prorated tuition.) I know there were folks in our class this year who were taking the class for a 2nd time, but I'm sorry that this friend will be in the same boat in the fall--now she has to wait through the summer, and she won't get to graduate with 'her' class, and she has to hope she can be successful in the fall (I think you can only repeat a class once). Yikes.
In our Bridging class, we received our assignments for our Bridging clinical, which is 64 hours with a nurse on the floor of a particular unit. I'll be on a cardiac floor (the floor that I did an elective on over winter break this year). We still have an instructor who monitors our progress and, ultimately, grades us. Most of us will do a combination of 8 and 12-hour shifts to reach 64 hours; I start mine with 2 12-hour shifts back to back. Anyway, that's still a couple of weeks off. My last day of it will be the day before convocation. The other half of our Bridging class was focused on the NCLEX exam. I can't remember whether I've written about this before, but the NCLEX is a national exam administered in each state. Candidates for the exam must possess (at least) an AAS in Nursing, which is what I will have after graduation. (I think some states require a BSN, but NY doesn't as of yet.) The candidate applies to the state for licensure, and at the same time sends an application to the testing company that administers the exams. After graduation, the candidate's school certifies to the state that the candidate did, in fact, graduate. The state processes all of this stuff and notifies the testing company that the candidate is eligible to take the test. The testing company then tells the candidate they may choose a date for the test. We've been warned that it's usually 6-8 weeks after graduation before you're approved to take the test and can get a test date. We've also been warned to fill out the applications very exactly--the state also performs a background check before agreeing to license you.
The last week of clinical went well. I liked this oncology floor a lot! Unfortunately, they don't have any job openings right now, but I'll keep checking... I did put in some other applications last week, so we'll see what comes of them.
Another week down! This week we had our 4th exam, which went okay but I didn't do as well as I hoped, and then learned about non-pharmacological pain management--everything from acupuncture to meditation to Reiki. I have to admit, I'm skeptical that 'energy field' therapies actually work (beyond a placebo effect--which can be very powerful and hey, if it works, great!--and beyond the 'caring presence' effect). However, hospitals--including the one associated with my school--are incorporating them into the clinical area, and patients can now request and receive these treatments in the hospital. There is a group of volunteers, many of whom are RNs, that provide the service. One of my previous clinical instructors is one of the Reiki practitioners, and I must say that she is, in every other way, a very focused, scientific, rational person...but then she said "please don't touch the tips of the essential oil bottles; it will destroy the vibrations." Sooo, I'm not sure that I will be convinced until I try it myself, and I think I have enough of a scientific bent to say "I won't be convinced until someone does it on me and I'm not aware of what they're doing and it works anyway."
[A non-school-related digression: My father is in the middle of moving out of the country, and he and a friend have bought a house. A series of unfortunate events have occurred to the friend in this house--nothing criminal or dangerous, but difficult to deal with nonetheless. The friend now believes the house is in some way cursed, or has a bad 'aura,' or something like that. My father is a scientist, and has never professed any religious faith. In fact, it's something he specifically disavows. I am a Christian, but a belief in evil spirits, or auras, or anything along those lines has never been personally resonant with me. But the other day my father and I--both admitted skeptics--had a serious conversation about whether having the aura of the house cleansed would help his friend feel at home there.
What's the point of that note? I guess, in the paraphrased words of Terry Pratchett, 'it would be a funny world if we were all alike.']
This was our second-to-last week of clinical. We also had our final simulation, which went pretty well in that we did not kill our 'patients.' The set-up was that we had two patients who were both at risk of going into shock, and if we didn't catch it quickly enough I think one (or both) would have gone into cardiac arrest. Then we would have had to do CPR and maybe they still wouldn't have made it. But, everyone (plastic mannequins and nursing students alike) survived!
In Tuesday, we finished learning about Shock in our Theory class, although I definitely don't think I've mastered this topic yet. I predict a lot of reviewing this weekend, since we have an exam next Tuesday. On Wednesday we had an overview of the history of nursing in our Bridging class and then had a guest-lecture from a burn-injuries specialist. The burn unit at the local Trauma-Center hospital also covers other epithelium-destroying diseases and injuries, such as chemical burns and flesh-eating bacteria. It was a good lecture, with some horrifying photos.
I spent the week in clinical this week in the one-day surgery wing of the hospital. This is a place where patients arrive for pre-scheduled surgeries and then (typically) spend the night before being discharged the next morning; some don't even stay the night. It's also the place where pre-scheduled patients report for surgeries after which they'll be admitted to one of the medical/surgical floors for a few days (such as knee-replacements). So, it can be very busy at times and very quiet at others (such as midday when everyone who arrived that morning is still in the OR and most-everyone from yesterday has been discharged). Because most of the patients are relatively healthy, the nurses' jobs seem pretty easy most of the time, but because all of the patients are post-operative, the nurses actually need to be pretty on top of things, since a patient could start bleeding, or have a bad reaction to anesthesia, or have other complications. Also, all kinds of surgeries pass through this unit--I saw patients with eye/ear/nose/throat procedures, spine procedures, gallbladder removals, gynecologic and prostate procedures, fistula-creation surgery for dialysis (fusing a vein and artery together), etc... This means the nurses need to be familiar with the assessments and complications for all of these types of surgery. On most other floors, you're more likely to have the same types of surgery--one floor gets most of the GI/pelvic/abdominal procedures; another gets the orthopedic procedures, etc... But not this unit! It was an interesting couple of days.
That's about all the news. I feel like my list of "lasts" is growing quickly now--we'll have our last simulation on Monday; our last week of clinical is only two weeks away, etc... Now if it would only get warm out, it might feel like Spring!
Our Bridging class this week featured a trio of three recent graduates sharing their experiences from their first year of practice with us. It was interesting, but also intimidating--they all talked about having instances where they'd cried because of the way another nurse had treated them, and it took all of them a few months after graduation to find and start work [some of that is because some agencies can't hire you until you've passed your certification exam; it's usually 6 weeks to 2 months before you're allowed to take the exam after graduation]. On the other hand, all of them survived their orientation periods, and seem to like the units they're working on now.
Thursday and Friday were, as usual, devoted to Clinical. I had 3 patients again this week, and each week I do makes me feel a little more confident about it! It's not actually a requirement of the program that we be able to manage 3 patients--just 2--but on most floors the nurses have 5-6 patients. (Of course, most staff nurses don't need to have someone else check all of their medications--just narcotics, chemotherapy, and other high-risk stuff! This adds a huge amount of time to our day, I think.)
This weekend I worked on one of the computerized exams we have to take for our Bridging class. Increasingly, I don't like them! They're written by an outside company, and the whole purpose (I think) is that they're supposed to help us review. The same company publishes review books--kind of a "Cliff's Notes" (does anyone still use those?) of various nursing topics. But the exams don't necessarily cover information from the review books, and the answers (which are displayed with 'rationales') often don't include any meaningful rationale. ie: if you didn't understand the concept before, the rationale provided won't help you understand it now! Anyway, we're required to do them, and the review books are provided for us (I'm sure we've paid for them in our tuition), but really I'd rather review from the actual textbook.
Okay, back to work. I'm trying to finish the 2nd written assignment for the Bridging class, but it isn't due until Wednesday and thus my brain does not want to work on it...
At any rate, another week done! I'm trying not to have a countdown in my head, but that's getting more difficult.
We began the week with an exam on the endocrine system, blood disorders (mostly anemias), and oncology basics. I felt pretty good going into the exam, but felt less confident after it was over. And we don't have our scores yet because one student was absent. We're supposed to get them tomorrow. Waiting a week is a long time! On Wednesday in our theory class we began learning about some autoimmune disorders (MS and ALS, mostly). We'll continue that unit on Tuesday.
Clinical went pretty well this week, I thought. I had 3 patients for only my second time, which was definitely daunting but I got through both days with no major hangups. Of course, it helped that 2 of the patients were pretty independent for all of their self-care. Nothing slows things down like an incontinent, bed-bound patient! Our clinical instructor for this rotation is very different from many of the other instructors. I can't decide whether this is good or not. She's much less strict and intimidating, but I'm also not entirely sure she's completely paying attention. On the one hand, we're really supposed to know what we're doing by now--and that includes asking for help or advice when we're not sure what to do. So, maybe we don't need someone watching us like a hawk (as some of the other instructors do). On the other hand, we're still pretty new at this, and I'm sure each of us misses things...not that I think anyone is providing unsafe care, but maybe we forget to document our assessment of how a pain medication worked, or we don't think about how two medications might interact. I like to think I'm conscientious enough that I do go to her when I need something, and in the meantime it's a relief to feel like every action isn't under quite so much scrutiny.
Bedtime! Well, after the dishes and some other tasks...
Anyway, in our Theory class last week we learned about endocrine system disorders. Specifically, we learned about hyper- and hypo-thyroidism, and adrenal insufficiency/Addison's disease, and adrenal excess/Cushing's disease. Since the hormones from the adrenal glands and the thyroid affect nearly every cell in the body (indirectly or directly), these are fairly involved disorders. (For example, if you have adrenal insufficiency, you do not make enough aldosterone (among other hormones). Aldosterone tells the kidneys to hold on to water and sodium. Thus, you lose excess water (becoming dehydrated), you lose sodium (which causes neurological problems), you retain too much potassium because you're losing too much salt (potassium affects muscle function, including the heart), etc...)
This was our first week on our new clinical units. As I mentioned, I'm on an oncology unit now, which a unit I'd been hoping to get some experience on. The first week went pretty well, though in part that was because I only happened to have one patient (people kept getting discharged and she eventually gave up on finding me a 2nd patient). This was great because I really got to spend a lot of time with the patient, who was getting ready for discharge after a long stay. It was also useful academically, because one of our assignments this semester is to do a Teaching Plan. The idea is that nurses do a lot of teaching for patients all the time, and we're expected to be doing that. But for this Plan, we need to take a look at everything the patient needs to learn about before being discharged--medications, equipment, treatments, general understanding of their illness, referrals and followup, and diet--and present it all to the patient. The hospital says "discharge teaching begins at admission,"--ie: we're always working toward the time when the patient will go home, even if there's no date on that yet. But this patient was actually being discharged, which meant that s/he was very interested in learning about all the things s/he and home-care will need to do. Having only one patient let me focus on this and have some good discussions. By the time I wrote it all up, it was about 11 pages single-spaced! It's graded as pass/fail, so now I just have to hope my instructor accepts it and I will have completed the assignment!
The nearness of the end of school is starting to push its way into my consciousness--I need to start applying for jobs soon; we'll be done with regular clinical at the end of April; I had to order my cap and gown the other day. At the same time, I know I need to remain focused--we have 4 more exams (and 3 more computerized ones) and then the NCLEX to get through! And, as usual, I won't feel really good about things until I get my evaluation from my instructor at the end of April.
Our Bridging class, which I've only rarely mentioned, is pretty relaxed. Mostly, we have some assigned readings, a couple of written assignments, and a couple of computerized exams at the end, along with 64 hours of clinical at the end of the semester. Lecture topics are based on issues that are important in terms of career development and adapting to the role of 'nurse' in a professional setting. Topics so far have included this concept of role-adaptation (many new nurses go through a fairly predictable course of adaptation in the years after graduation); leadership; conflict resolution; teamwork; etc... This past week, one of the other nursing instructors who is also a legal expert talked to us about Ethics. It was well-timed, in light of the recent California nursing home death. (If you've somehow missed hearing about this, an independent-living resident of a multi-level-care facility collapsed in a dining area. A recording of the 911 call, in which a person who claims to be a nurse refuses to give CPR because of 'agency policy,' has circulated the media this week.) Our class was held on Monday, and the event had just occurred over the weekend, so few details had been published yet. However, it was a good example of the type of ethical difficulty [ie: when two needs are in direct, unresolvable conflict with each other] a nurse may be required to face--violate policy and potentially lose her job vs. try to save someone's life. (Personally, I feel like this one is a little more clear-cut than other ethical dilemmas might be. As one of the Emergency Department nurses told me, "If you're ever asking yourself 'should I be doing CPR right now?' the answer is 'yes. Do CPR.'")
Our simulation this week was based on Management and Delegation, but the structure of it was a little strange. First, normally 2 groups of 6 do their simulations at the same time. Within each group, one student is assigned to be the 'primary' RN, one the 'secondary' RN, and one the Charge nurse. One person is a 'family member' (and has a script), and the remaining 2 are observers who help the group critique their process at the end. It's stressful being one of the nurses, but no one is graded on the simulation (just on the written prep work we have to do). For this simulation, they chose one group to actually perform and the entire other group observed, along with the observers from the performing group! We'll switch groups for our last simulation. My group was the observing group, so we just had to watch! The nurses in the performing group had 2 patients, one of whom seemed to be the 'higher priority' at first--abnormal labs, various other issues. But in the middle of the time, the other patient became distressed and also needed attention. The 3 nurses had to figure out what to do and when to do it. Ultimately, it was more an exercise in prioritization than delegation (for example, there were no 'nurse aides' to whom some tasks could be delegated).
In our Theory class, we continued learning about blood disorders (anemia, leukemias, and lymphomas) and then did a short unit on oncology (focusing mostly on breast cancer as a general exemplar). I also learned that I'll be assigned to the oncology floor for our final rotation. I was hoping for this--I think it's an area where I'd like to work--but I'm nervous about it at the same time. I'm well aware that there could be patients on this floor whose situation is very similar to my mother's. This could be hard for me to cope with, but also (and I think this will be harder) difficult to tread the line between hope and realism. I've accepted the fact that my mother's death was medically inevitable, but I think it's better that she never knew that until the very end (the last few days of her life). I'm not talking about deception--all of the scans and tests that the doctor ordered just didn't show how far the cancer had spread until the final, revealing, liver biopsy. So, I expect this floor to bring some new challenges!
We only had one day of clinical this week, because our instructor was sick the first day. Usually on Thursdays we are there from 0700-1500 (ie: 7am to 3pm, and most of us arrive early). On Fridays we're there from 0700-1200 and then have a post-conference until 1300-ish. Thursdays are usually more stressful, because the 'normal' rhythm of the morning is
0600-0700: Read new orders for each patient, check the medication administration books to find out when they get meds, look up any meds you're not familiar with, find paperwork you'll need (like the doctor's order for parenteral nutrition, which has to be written every day and the contents should be confirmed by every shift), etc... At 0700 the day nurses arrive. They get report on each patient from the night nurses. We can't go in to see a patient until we've gotten report, either at the same time as the day nurse or after s/he's seen the night nurse. This time of day seems astoundingly inefficient--it often takes until 0745 for everyone to have report
Meanwhile, the doctors arrive on the floor between 0800 and 0900, which means they want to see the vital signs and nursing assessments from the morning nurses. We're supposed to complete our assessments (including vital signs; the regular RNs usually have an aide who takes vitals for them) and document them in the computer by 0830. Some patients also receive medications at 0800, so these have to be given by 0900 (there's a 60 minute +/- window for most meds). Patients who are diabetic receive insulin with their meals, and breakfast usually arrives on this floor around 0900. So, diabetic patients need a finger-stick to check their blood sugar around 0845, but then you have to wait to see how much breakfast they eat before drawing up their insulin.
Meanwhile, at 0900 you can start preparing your medications for 1000. 1000 is the primary time for medications on most floors. Any medication we give must be checked by our instructor who will also quiz us on the purpose of the medication and make sure we've done any necessary assessments before giving it (like checking the blood pressure before giving a blood pressure med). If the medication is intravenous, the instructor must be present while we give it, whether we're doing it by 'push' (the new skill we learned a couple of weeks ago) or hanging a bag of the medicine and connecting it to their IV fluid pump. The instructor can't be in more than one place at once, so it's definitely a challenge to get meds together for multiple patients, even within a 120-minute timeframe!
We're also responsible for helping patients wash up, changing their linen each day, getting patients up & out of bed, and dealing with anything else that might come up (incontinence, emptying tubes and drains, requests for pain medication, a glass of water, etc...). Some of those things can really eat up time--and it's not that I don't want to do them, but it's just a challenge do get it all done! So, theoretically by 1100 the morning has calmed down a bit (or that's finally the time that you can help a patient get bathed), but some patients also have 1200 medications, and many patients have their vital signs taken every 4 hours (so, at 1200), and then finger sticks for lunch must be done around 1245 with insulin coverage to follow.
The second busiest time for medications seems to be 1400, and then by 1430 we're expected to have tallied up all intake and output for the shift (and entered it into the computer), written a note in the chart about our care that day (this has to be handwritten first and checked by our instructor), and reported off to our RNs so we can leave by 1500. Throughout the day, we also have to adapt to new orders (which could include getting a newly ordered medication to the patient, or changing the type of IV fluid, or getting the patient ready to go to a procedure).
On Fridays, we don't do any of the noon medications, vitals, or finger-sticks, so as long as we get through the 1000 med rush, it's a little easier! This week was the very first week that I've had 3 patients. Other students have had 3 patients for a couple of weeks, but because I was assigned to be team-leader 2 weeks ago, and was in the ED last week, this was my first day. It went okay, but could have been better. I got really tied up in a task at the beginning of the morning and that put me behind... I'm definitely starting to feel some dread about the approaching end of the semester. On the one hand, graduation is the goal of these 2 years of hard work! On the other hand, I feel like I've figured out the role of "student nurse" and soon I'll just be a regular nurse! All the while, I have to keep saying "I should graduate in May," because we really don't have our final "are-you-ready-to-graduate" evaluations until the last 2 weeks of the semester. I feel like everything is up in the air until then. (We just have to keep working hard and trying to improve.)
So, anyway, apart from all that, we started learning about the hematologic (ie: blood) system this week in Theory. We'll finish that up and do a brief unit on oncology next week. We also have another simulation next week.
We did have a simulation, which we do in our lab on a computerized mannequin-patient. These sound like a good idea, but I'm actually finding them to be frustrating. They are operated by an instructor in a remote room, who can see/hear the whole simulation room by a camera and microphone. In theory, you can take a pulse and blood pressure on the mannequin. In actuality, both the pulse and blood pressure sound different and are harder to find than they are on a real patient. So, we wind up wasting a lot of time (IMO) dealing with that rather than moving forward to the 'meat' of the simulation (which, in this case, would have included watching the patient's heart rate drop as his potassium level rose because his kidneys weren't eliminating it, and then requesting orders from the doctor to treat the problem). Fortunately, we don't get graded on the simulation itself, just on the preparatory write-up we have to do.
In clinical this week, I was in the Emergency Department. I'll be back up on my normal floor next week, but we each get assigned to one week in another department each rotation. The ED was definitely interesting! I can't talk a lot about what kinds of stuff I saw (too specific), but overall there were a lot of patients with chest pain (but no heart attacks), respiratory distress, cold & flu symptoms, altered mental status (from "just not acting right" to "I got dizzy and fell down,"), alcohol intoxication, patients requesting detox (this hospital has an inpatient detox unit), and bumps/sprains/etc... In NYS, RNs can't work in an ED until they have at least 1 year of medical-surgical experience. Because both days I was there were relatively quiet, the RNs had pretty relaxing days, it seemed. However, all of them must be Advanced Cardiac Life Support certified (regular nurses are just Basic Life Support certified), Pediatric Advanced Life Support certified, etc... Although there is a larger trauma center in another hospital in town, any hospital may receive almost any type of patient and must be ready!
Anyway, we continued to learn about kidneys and kidney failure this week. Protect your kidneys, y'all. They are super-important. Next week we have an exam that is almost entirely devoted to kidneys (with a little bit of management/delegation and IV Push thrown in).
In our Bridging class, which I realize I've omitted for the last few weeks, we learned about temperaments and management styles. Basically, we took the Keirsey temperament sorter and then talked about what the letters meant, especially in a teamwork-type setting. For anyone who is interested, I came out as an IST/FJ. I've taken Myers-Briggs tests before for various reasons and have usually come out to be an INFJ. This time I was more strongly and S and a dead tie for T/F. And a very strong I and J, which will be a surprise to no one. I did find the descriptions of ISTJ and ISFJ interesting (and reasonably accurate, but I still have a lot of N) mostly because of they both describe the typical response to stressors as "catastrophizing." Oh, yeah. I've felt like this is more and more true in the last few years, and I don't know whether it's because of the stress of school and some family/personal stress, or whether--as I get older--I'm just going to be more likely to think of the worst-case scenario for stuff?
In Clinical this week, I was the 'Team Leader' which sounds like an honor (maybe) but is really just a chance to experience trying to keep track of 5 other students and 13 patients! It wasn't bad, but the Team Leader is more like a resource person/troubleshooter/organizer. My instructor assigned me to it this week because time management and organization continue to be big issues for me. Next week I get to spend both days in the emergency department, which I'm looking forward to.
Now, though, dinner and then probably early bedtime. Getting up at 0430 makes me sleepy....
On Tuesday we had our math exam, which I passed. I know of a few students who didn't pass, but they have 2 more chances and most of them seemed to know what they had done wrong (failing to label units correctly in your answer will cause you to fail, for example). Then we had a theory lecture on management, prioritization, and delegation. One of the things an RN needs to be able to do is to delegate certain tasks to LPNs or nursing assistants--but only certain types of tasks can be delegated, and only under appropriate circumstances. For example, an RN could delegate feeding a dementia patient to an NA if the patient had no recent changes and was a 'known quantity.' But an RN should not delegate feeding a patient who was just admitted with a stroke, because this patient might be prone to choking and the RN needs to assess for this risk. Only RNs are allowed to assess a patient. Likewise, only RNs are allowed to teach, but LPNs could reinforce teaching.
Our Wednesday theory lecture started a 3-class series on the kidneys, which will make up the bulk of our 2nd exam. We learned about benign prostatic hyperplasia and kidney stones. Next week we'll learn about kidney failure.
Thursday and Friday were devoted to clinical, as usual. In past semesters, we have had to do fairly extensive write-ups about our patients as we learn to tie all of their secondary and primary diagnoses together with their treatments and nursing interventions. This semester, we started off by doing a similar write-up, but after 2 of them have been deemed 'successful,' our instructor lets us know that we don't need to do them any more. Woo hoo! My first 2 were successful, so for the next 4 weeks I don't need to do them (but I still need to know the information that would have been included in the packet). I'm not sure about the 2nd 6 week rotation--we move to new instructors on new floors, so no one is sure if we do new packets as well. For now, though, I'm not complaining!
We didn't have any new theory in class this week, which I think is a little weird, but that's the way they wrote the schedule. We start to learn about the renal (kidney) system next week, as well as management and delegation. We also have the first of our mandatory math tests for the semester. These don't count towards our grade, but we must get 100% or take it again. If a person fails to get 100% after 3 tries, they have failed the entire semester. I'm not actually aware of anyone who has had to repeat a semester because of this, but I'm sure it has happened.
We had our second week of clinical this week, which I thought went better than last week! Our instructor has warned us, though, that she's going to start expecting more and more of us--I think not so much in terms of "more tasks" but "more thought, more assessment, and more problem solving." The idea is that by the end of the semester, we need to have developed at least a rudimentary amount of "nursing judgement," whereby we identify an abnormal finding, assess all of the pertinent information, and then decide what to do--which might include calling the doctor or NP, but that's not the first step. So, for example, if a patient suddenly complained of being short of breath after walking a short distance, we'd need to measure their pulse oximetry (that little finger clip with the red light), listen to their lungs, identify whether they were in pain, and check the level of oxygen they are receiving (if they have external oxygen). Then based on those findings we might decide "the lungs sound okay, but the patient needs to use their inspirex (a device they breathe through that promotes fuller lung expansion), and needs to wear an oxygen bottle when walking around" or "there are some crackles in the lungs where there weren't before. This could mean fluid is building up. The patient needs to walk a lot, deep breathe and cough frequently, and use their inspirex." or (maybe) "I can't hear any breath sounds on the right hand side, and I could earlier. We need to notify the doctor right away." But most likely, this is not the case, and the nurse is the one who needs to gather the information to make this call. Even though this sounds kind of simple, it's definitely a habit we need to actively develop. In part, this is because for the last 3 semester we've been taught to come to our instructor immediately with any abnormal findings. This is because we didn't necessarily have the knowledge yet about what these findings might mean. But by now, we should have the knowledge base to understand/interpret the data we gather when doing our assessment. (Of course, we still have to let the instructor know! But we need to come to her with *all* the information, not just "my pt is short of breath.")
In our theory class this week we learned about cirrhosis on Tuesday and then learned about interpreting EKG strips on Wednesday (and what the implications are for the patient). I definitely need to work on the EKG strips--they're on our exam coming up this week, and we need to be able to recognize and identify about 12 different patterns. We're not learning this in as much detail as a cardiologist would (of course) but the differences between some patterns are fairly subtle. Apparently in some hospitals, nurses provide the interpretation of the patient's heart rhythm and use this to decide whether to notify the cardiologist. (In the 2 hospitals where I've done clinical work, there is a telemetry department. On some floors, they even have a station at the nurses' station, and they monitor all the patients from a big bank of computers. On other floors, the patient's monitor transmits the info to a remote monitoring station and we can pick up a red phone (yes, it really is red, and it *only* connects to the telemetry department) to find out what a patient's rhythm is.
We also started a new class this week, which is called Graduate Bridging Experience. It addresses various topics related to making the transition from the sheltered world of student nursing to the imperfect world of professional nursing. At the end of the class, we'll do 60+ hours of clinical with a preceptor. Until then, it's mostly lecture content with a couple of written assignments.
We started clinical this week on Thursday and Friday. I'm on a medical/surgical floor that tends to handle GI issues (but, like all med/surg floors, gets all kinds of patients). I didn't have a great week--I felt like I was always behind, despite having only one patient the first day--and I definitely need to be more assertive with patients in order to get things done. Yarr. Our instructor is very nice (and not as intimidating as some of the instructors at this level seem) and I think she was pretty forgiving this week, but I still felt like I didn't do a very good job. I know it just means that I can show improvement in future weeks, but it certainly raises my anxiety level! Throughout this program, I've felt confident academically but I always feel like my clinical work is my weak area. Not that I've done anything unsafe--just that I get bogged down by certain tasks and don't accomplish everything I should (or when I should). This is not the only thing we're graded on, but organization of care is definitely something we need to be able to do!
This coming week, we have our first exam in our Theory class, and then no Theory class on Wednesday. This means no new content for the week, which I think is a little strange. Our schedule is very irregular this semester--our Theory class is supposed to meet from 12-2:15, but they've tried to combine us with the evening group on some days, so in reality we meet for 2.25-3.5 hours 1 or 2 days a week, at a time between 12 and 7pm! None of us are happy about that--least of all, people with kids, jobs, or both, who had been anticipating a regular schedule. Until this semester, I had been really impressed at the way the school tries to issue very clear schedules and notify us of changes well in advance. This semester, though, it feels like they've basically said "you're in your final semester. We know you're not going to drop out, so we can screw up the schedule any way we want and you'll make it work because you want to graduate." It's a little frustrating, even though I'm not working and don't have childcare to schedule! My favorite part, though, is that when they torqued the schedule around, they scheduled some of the lectures at the same time as Intro Sociology, which is a co-requisite for this class! Granted, many of us have already taken it, but several students haven't (because, after all, it's not required until the 4th semester, and when we registered for classes, the schedule clearly showed that they met at different times)! Anyway, that is probably more than you wanted to hear about all that!